Photo by © ASCO/Todd Buchanan 2011
Every year around this time, there's a scheduled pilgrimage for clinical oncologists. From all over the world they flock, young and old, to attend the Annual Meeting of the American Society of Clinical Oncology (ASCO).
Although the attendance numbers vary from year to year, there is on the order of 25,000 professional attendees and about 4,500 scientific abstracts available for review and discussion. As I prepare to return home to Houston after this 2011 meeting, I have the familiar mixed feeling of inspiration and physical exhaustion.
The exhaustion is easy to understand. Each day, there are innumerable scientific and educational sessions integral to the ASCO meeting itself. Then there are side meetings with other agencies, institutions or colleagues planning and monitoring various projects. In addition, more meetings with friends and mentors who are treasured yet seldom seen in the ordinary flow of a frenetic work life.
What about this experience was so inspiring?
ASCO is chock-full of people who want to cure disease, comfort patients and make a difference in their institutions and communities. The whole experience resonates with words expressed by the head of MD Anderson's Division of Cancer Medicine, Waun Ki Hong, M.D., who recently spoke to colleagues about key attributes of a successful academician: sacrifice, creativity and mentorship. While ASCO is far more than a group of academicians, these three concepts shine bright throughout the meeting and provide a yearly lift to those of us who care for cancer patients.
At this year's meeting, focusing on the patient care and survivorship track of new information, there were a few themes and tidbits that caught my attention (with abstract numbers in parentheses):
Placebos remain a formidable adversary.
• Symptom researchers routinely compare new interventions to the effect of a placebo intervention, and the placebo wins most of the matchups every year. So we learn that flaxseed doesn't help hot flashes in women (CRA9015) and acupuncture doesn't solve the problem of post-chemotherapy fatigue (9029). An L-arginine supplement with ginseng and ginkgo biloba doesn't improve female sexual dysfunction post-treatment (9016). Alpha lipoic acid pills don't prevent neuropathy (9010). A gel made of three anti-nausea medications often applied to the skin of hospice patients who can't swallow pills doesn't work because the drugs aren't absorbed from the skin (9021). And most aggravating of all is that buspirone actually has a worse effect on shortness of breath than placebo (9023).
Research is tough and it can be frustrating. This year, there was even a special session at ASCO called, "Why isn't research more successful?"
The key to progress is a better understanding of the biology of symptoms and well-characterized biologic targets for interventions.
• David Steensma, M.D., provided great examples of symptom science, sharing how serum hepcidin measurement may be a predictive biomarker of response to iron supplementation when erythropoietic agents are used to treat anemia (9031). Also impressive was data presented by Patricia Ganz, M.D., showing the promising correlation between soluble TNF receptor type 2 and the occurrence of cognitive complaints in breast cancer survivors. The correlation between cytokine levels and symptom burden was demonstrated by Drs. Rich (9046) and Wang (9094), as well.
But the big hitter in correlative science data in symptom research was presented by Schneider and colleagues regarding a genome-wide association study (GWAS) in more than 2,000 patients. They found that a missense single nucleotide polymorphism (SNP) in RWDD3 was associated with likelihood of neuropathy, due to taxane-based adjuvant therapy for breast cancer (1000). This sort of data improves our chances of constructing clinical trials that will lead to practice changes.
The science of mind-body interventions is stronger than ever.
• Perhaps the most elegant and unique interventional study data I saw was presented by Lorenzo Cohen, Ph.D., demonstrating the strongest science yet to indicate that yoga itself (not just getting supportive attention and doing some gentle exercise, but actual yoga) is an effective intervention to improve symptoms and quality of life in women receiving radiation therapy for breast cancer (9009). Along with the self-reported data, he also measured serum cortisol and heart rate variability and demonstrated functional biologic changes that correspond to this improvement with yoga.
The importance of effective communication.
• One paper after another strengthened my belief in the importance of effective communication. For example, basic smoking cessation counseling (per quality guidelines) is associated with improved survival in the care of lung cancer patients (6074). There are some hints that communication will be needed to help patients make decisions if and when there are payor inducements to accept less-effective therapies (6068). Finally, communication with patients and caregivers makes an enormous difference in quality of life and resource utilization toward the end of life (9041), to clinical trial enrollment (6040) and to the ability of patients and families to understand and cope with treatment choices that have significant consequences on their personal finances (6065).
These papers remind me of Rachel Naomi Remen's observation that "the most important questions don't seem to have ready answers, but the questions themselves have healing power when they are shared." Ahhh, the power of words.